Medicaid expansion under the Affordable Care Act (ACA) was associated with improved outcomes for non-white patients with diabetic foot ulcerations, researchers reported.
Non-white patients with diabetic foot ulcerations residing in a Medicaid-expansion state had a 17% decreased risk of major amputation at the knee (OR 0.83, 95% CI 0.71-0.96), reported Tze-Woei Tan, MBBS, MPH, of the University of Arizona in Tucson.
Patients in states that adopted Medicaid expansion also had a 14% increased risk of minor amputations at the toes or feet (OR 1.14, 95% CI 1.03-1.27), suggesting access to healthcare in time to prevent more serious outcomes, Tan said in a presentation at the American Diabetes Association virtual meeting.
States that adopted the expansion had a 180% increase in the number of hospital admissions among Medicaid enrollees, and a 21.5% decrease among the uninsured.
“The increased risk of minor amputation among those living in early-adoptive states might reflect that patients are receiving or seeking care earlier,” Tan said. He added that more widespread insurance coverage and reduced risk of leg amputation were signs that increased access to care could reduce racial and ethnic gaps.
“The broadening of the ACA may reduce the disparity of lower extremity amputation among minorities with diabetes,” Tan said.
Asked for her perspective, Jennifer Lobo, PhD, of the University of Virginia School of Medicine in Charlottesville, who was not involved with the study, said the combination of reduced risk of major amputation and higher risk of minor amputation “suggests that increased insurance coverage allowed for patients to receive care before the point of major amputations was necessary.”
In an email to MedPage Today, Lobo, who has previously researched the effects of Medicaid expansion on insurance access among diabetes patients, added that she is hopeful that greater insurance coverage will boost the number of patients getting care even earlier in the disease process, reducing the risk of both major and minor amputations.
Diabetic foot ulcerations are the most common cause of lower extremity amputation in diabetes patients, Tan noted. Foot ulcers are associated with impaired physical function, reduced quality of life, risk of leg amputation, and death. Previous research found that after a diabetes-associated lower extremity amputation, more than 50% of patients die within 5 years.
Non-white patients have elevated risks of diabetes, foot ulcerations, and leg amputations compared with their white counterparts, with a risk of leg amputation 30-50% higher for African American, Hispanic, and Native American patients, Tan noted. He and his colleagues, therefore, aimed to evaluate how expanded access to insurance might affect diabetes care for patients in non-white communities.
The team analyzed inpatient databases from 19 states to identify the insurance status and health outcomes of patients with diabetic foot ulcerations from 2013 to 2015, dividing the study cohort into two groups: early-adopter states, which adopted Medicaid expansion under the ACA in January 2014, and non-adopter states.
Logistic regression models examined the effects of state type (early-adopter vs non-adopter), time (before or after the ACA), and interaction on risks of amputation.
The analysis included 25,493 non-white patients enrolled in Medicaid, and 9,863 who were uninsured. Patients were between 20 to 64 years old, and all had diabetic foot ulcerations.
The results showed that while the risk of major amputation decreased in states that adopted Medicaid expansion, non-adopter states saw a 0.9% increase in risk among minority populations with diabetic foot ulcerations (OR 1.009, 95% CI 0.89-1.14). The risk of minor amputations decreased 8.1% in non-adopter states (OR 0.92, 95% CI 0.84-1.01).
Lobo said policies that expand healthcare through increased insurance coverage and greater access to specialty care can reduce major complications and disparities among diabetes patients. The study by Tan and co-authors “underscores the need to increase access to care, particularly among those states that have not yet elected to expand Medicaid,” she added.
Disclosures
The research was supported by the National Institutes of Health and the National Institute of Diabetes and Digestive and Kidney Diseases.
Tan and co-authors disclosed no conflicts of interest.
Source: MedicalNewsToday.com
